Mpox Surveillance Based on Rash Characteristics — 13 Emergency Departments, United States, June–December 2023

In 2022, a global mpox outbreak occurred, primarily affecting gay and bisexual men who have sex with men (GBMSM). To screen for mpox's reemergence and investigate potentially unsuspected cases among non-GBMSM, prospective surveillance of patients aged ≥3 months with an mpox-compatible rash (vesicular, pustular, ulcerated, or crusted) was conducted at 13 U.S. emergency departments (EDs) during June-December 2023. Demographic, historical, and illness characteristics were collected using questionnaires and electronic health records. Lesions were tested for monkeypox virus using polymerase chain reaction. Among 196 enrolled persons, the median age was 37.5 years (IQR = 21.0-53.5 years); 39 (19.9%) were aged <16 years, and 108 (55.1%) were male. Among all enrollees, 13 (6.6%) were GBMSM. Overall, approximately one half (46.4%) and one quarter (23.5%) of enrolled persons were non-Hispanic White and non-Hispanic Black or African American, respectively, and 38.8% reported Hispanic or Latino (Hispanic) ethnicity. Unstable housing was reported by 21 (10.7%) enrollees, and 24 (12.2%) lacked health insurance. The prevalence of mpox among ED patients evaluated for an mpox-compatible rash was 1.5% (95% CI = 0.3%-4.4%); all persons with a confirmed mpox diagnosis identified as GBMSM and reported being HIV-negative, not being vaccinated against mpox, and having engaged in sex with one or more partners met through smartphone dating applications. No cases were identified among women, children, or unhoused persons. Clinicians should remain vigilant for mpox and educate persons at risk for mpox about modifying behaviors that increase risk and the importance of receiving 2 appropriately spaced doses of JYNNEOS vaccine to prevent mpox.


Introduction
On May 23, 2022, CDC activated its mpox outbreak response, and on July 23, the World Health Organization declared mpox a Public Health Emergency of International Concern (1).Approximately 30,000 U.S. clade II mpox cases were reported in 2022; although cases declined sharply during late 2022, mpox has continued to spread at low levels.* ,† Whereas the majority of infections occurred among gay and bisexual men who have sex with men (GBMSM) (1), cases also occurred among women, children, and other persons with no reported sexual contact, including those experiencing homelessness or working in crowded settings (2).Serologic surveys during the peak of the outbreak suggested that some cases went undiagnosed, although the rate of undiagnosed cases among persons at high risk was low (3).
Concern regarding mpox resurgence is related to low vaccination coverage among persons at risk for mpox, the possibility of infection in persons who have been vaccinated, and incomplete knowledge about risk factors among persons living in congregate settings (4,5).Recent reports have described mpox outbreaks in major U.S. metropolitan areas, including Chicago (March-June 2023) (6) and Los Angeles (May-August 2023) (7).
Emergency departments (EDs) disproportionately care for persons with increased risk, including those susceptible to contracting infectious diseases, sexual and gender minorities, persons living with HIV, and those who are unhoused, work or live in congregate settings, and abuse alcohol or other drugs.Therefore, to screen for mpox's reemergence among all potentially affected persons, surveillance based on rash characteristics, rather than epidemiologic risk factors or clinician suspicion, was conducted through EMERGEncy ID NET (https://www.emergencyidnet.org),a U.S. ED-based emerging infections surveillance network.

Study Design and Enrollment Qualifications
A multicenter observational mpox surveillance project was conducted at 13 ED hospital sites.§ During June-December 2023, patients aged ≥3 months evaluated in a participating ED with an mpox-compatible rash, defined as one or more lesions that appeared pustular, vesicular, crusted, or ulcerated, were enrolled.A qualifying rash was the only entry criterion; epidemiologic mpox risk factors and other illness characteristics were not considered inclusion criteria.Site coordinators received instruction and ongoing feedback regarding rash identification and characterization from project principal and site investigator physicians.Exclusion criteria included the following conditions: 1) previous enrollment, 2) predesignated as not wishing to participate in research, 3) not English-or Spanish-speaking, 4) unable to provide consent, 5) rash present for >4 weeks, and 6) only lesions >2 cm in diameter, excluding erythema.During the enrollment visit, demographic, historical, and illness characteristics were collected through patient (or parent) and clinician questionnaires; electronic health record review was completed 5-7 days after the enrollment visit.Two skin swabs were collected from lesions located on different body sites (when possible) from each patient.Swabs were tested at UCLA Clinical Microbiology Laboratory by polymerase chain reaction (PCR) that included targets for both nonvariola orthopoxvirus and monkeypox virus.

Assessment of Sensitivity of Case Finding
To assess case-finding sensitivity and characterize differences between enrolled and eligible nonenrolled patients, project sites performed monthly audits of project-qualifying nonenrolled ED patients and those receiving hospital mpox PCR testing based on the ED provider's clinical and epidemiologic suspicion during the patient's usual ED care, which occurred independently of the solely rash-based mpox surveillance project.Audit lists included project-eligible ED patients with rash associated with International Classification of Diseases, Tenth Revision (ICD-10) codes R21 (rash and other nonspecific skin eruption), B00 (herpesviral [herpes simplex] infections), B01 (varicella [chickenpox]), B02 (zoster [herpes zoster]), B03 (smallpox), B04 (monkeypox), and B08 (other viral infections characterized by skin and mucous membrane lesions), and with usual-care mpox PCR testing orders.Demographic and illness characteristics of enrolled and eligible nonenrolled patients were compared.

Data Analysis
Descriptive statistics were used to characterize the study population.The frequency of PCR-diagnosed mpox among ED patients evaluated for an mpox-compatible rash and 95% CIs were calculated using the test of binomial proportion.Data were analyzed using SAS statistical software (version 9.4; SAS Institute).This activity was reviewed by the participating sites' institutional review boards, deemed not research, and was conducted consistent with applicable federal law.¶

Rash Characteristics
Enrollees had a median of 10 lesions, with a median lesion diameter of 0.5 cm (Table 2).Rashes were described as vesicular (50.5%), crusted (41.8%), pustular (27.0%), and ulcerated (22.5%).Twelve (6.1%) participants were assessed by their  Abbreviations: ED = emergency department; HPV = human papillomavirus; PCR = polymerase chain reaction; SNF = skilled nursing facility; STI = sexually transmitted infection; URI = upper respiratory infection.* participants had lesion counts noted as "too numerous to count" and were not included in this calculation.Lesion counts were missing for four participants.† Second rash swab was not obtained from six participants.§ Two patients receiving testing through the surveillance project were also suspected through their usual ED care of having mpox and received hospital mpox PCR testing.Both patients received positive mpox test results by the surveillance and hospital laboratory tests.¶ Number with positive test result among total number tested.
treating ED clinician as being likely or very likely to have mpox as the cause of their rash, and 13 enrollees (6.6%) underwent usual-care testing for mpox.

Mpox Patient Characteristics
Among all 196 enrollees, three (1.5%) received a positive monkeypox virus PCR test result; all three identified as GBMSM and reported being HIV-negative, not vaccinated against mpox, and having engaged in sex with one or more partners they met through smartphone dating applications (Table 3).All three patients were assessed by the treating ED clinician as being "very likely" to have mpox.No mpox cases were identified among women, children, or persons experiencing homelessness.

Comparison of Enrolled and Eligible Nonenrolled Participants
A total of 67 patients received testing for mpox at hospital laboratories at study sites as part of their usual ED care (13 of whom were also enrolled and tested through the project); three (4.5%) received positive test results, two of whom were also identified in the study.Among all 196 enrolled participants, 13 (6.6%) also received usual-care testing, two of whom received a positive hospital PCR test result, which was  concordant with the project test results (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/157005)(Table 2).Among 991 nonenrolled patients with qualifying rash associated with ICD-10 codes, 54 (5.5%) received usual-care testing for mpox, one (1.9%) of whom received a positive result.This patient, a male aged 25 years, was not included because he was examined in an ED during a period outside of project staff member coverage hours; no further demographic or risk information was available.Overall, the enrolled population was demographically similar to the eligible nonenrolled audited patients, but enrolled patients were more likely than were nonenrolled patients to have been admitted to a hospital (17.9% versus 9.9%).

Discussion
During June-December 2023, the prevalence of mpox among patients in 13 U.S. EDs who were evaluated for an mpox-compatible rash was low: among 196 enrolled patients, three (1.5%) received a positive monkeypox virus PCR test result, all of whom were unvaccinated GBMSM who engaged in sexual activity with partners they met through smartphone applications.Only an estimated 23% of the U.S. population at risk for mpox exposure had received vaccination during May 2022-January 2023 (8).No cases were identified among women, children, and unhoused persons.These findings add to a body of evidence indicating that mpox continues to circulate among persons at risk for mpox, primarily GBMSM with sexual risk factors (4,6,7), and underscore the importance of educating persons at risk for mpox regarding behavioral risks and encouraging these persons to be vaccinated (9).

Limitations
The findings in this report are subject to at least four limitations.First, the project was limited to 13 EDs and included a small sample size; thus, these findings might not be generalizable to other areas.Second, case-finding sensitivity was suboptimal because site staff members were unable to enroll all eligible patients for reasons that included the lack of night and weekend project personnel coverage and rapid discharge of eligible patients.However, the representativeness of the project population was supported by the audit, which indicated that enrolled and nonenrolled eligible patients were demographically similar and included a similar proportion of persons for whom hospital mpox testing was ordered by clinicians as part of their usual ED care.Further, approximately three times as many project patients received mpox testing (196) as did ED patients who received usual ED care (67), which identified only one additional case.Despite the presence of Abbreviations: ED = emergency department; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; NH = non-Hispanic; STI = sexually transmitted infection.